2. outlines
Definition of documentation
Importance of documentation
Guidelines for good documentation
Do's and Don'ts in documentation
Methods of documentation
Documentation forms
References
3. objectives
At the end of this presentation each student will be able to
Define documentation
Recognize the Importance of documentation
Identify the guidelines for good documentation
Mention Do’s and Don'ts in documentation
Identify Methods of documentation
List Documentation forms
4.
5. Definition
Involve all written and electronic entries reflecting
all aspects of patient care communicated, planned,
recommended or given to that patient
6. provide a structured and standardized approach to nursing
documentation for inpatients.
essential for good clinical communication.
provide an accurate reflection of nursing assessments, changes in
conditions, care provided and patient information to support the
multidisciplinary team to deliver great care.
provide evidence of care and protect nurse patient and organization
rights
Research and education
Importance of documentation
7. Guidelines for good documentation
the nursing documentation must be :
Factual
accurate
current
organized
complete
8. Do's and Don'ts
DO'S
Write all notes in blue or black ink
The patient’s name room medical record must be written on each
record form
Document date and time of each recording
Use correct spelling
Document event in the order they occurred
Use only commonly accepted abbreviations and terms that are
specified by the agency
Place your signature at the end
9. Do's and Don'ts cont,
Don'ts
DON'T Erase written mistakes or scratch over a word ,
note error by lining throw it writing ”error” and insert
your initial
DON'T Destroy or modify notes previously Witten
DON'T write procedures to be done until they have been
done
DON'T Leave blank or space in paper
10. Methods of documentation
o Narrative charting
o Source oriented charting
o Problem oriented charting
o PIE charting
o Focus charting
oCharting by exception
o Computerized documentation
11. cont,Methods of documentation
o Narrative charting:
Describe the client status , intervention
,treatments and response to treatments in
story like format
12. Methods of documentation cont,
o Source oriented charting
o Narrative recording by each member of health care team
on separate records
13. cont,Methods of documentation
o Problem oriented charting
uses structured logical format called SOAP
(Subjective, Objective, assessment, Plan)
15. Methods of documentation
Focus charting
Method of identifying and organizing the narrative
documentation of all client concerns
Uses columnar format within the progress notes
progress notes are organized into Data, Action and Response
Date and time focus progress notes
03 Jan 2017 acute pain related to CS D: pt report pain as 8/10 on 0-10 scale
A:give nalufin 5mg iv
R:pt report pain as 1/10
16. Methods of documentation cont,
o Charting by exception CBE
• The nurse only documents deviations from pre-established norms
(abnormal or significant findings)
• avoid lengthy repetitive notes
17. Methods of documentation cont,
Computerized documentation
• Increase quality of documentation and save time
• Increase legibility and accuracy
• Facilitate statistical analysis of data
18. 1. A Kardex
2. Flow sheets
3. Nurse's progress notes
4. Discharge summary
Documentation forms
19. Reference
Sophie Linton, Kylie Moon
http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_docu
mentation/
College of Registered Nurses of British Columbia 2013
https://www.crnbc.ca/Standards/Lists/StandardResources/151NursingDocume
ntation.pdf
http://www.conursing.uobaghdad.edu.iq/uploads/others/d.ali%20d/Nursing%20
Documentation.pdf
